Background
Methods
Recruitment
Data collection
Data analysis
Results
Interviewee characteristics
Interviewee code | Health Board Region | Description of Health Board Region | Adult weight management tiers and referral pathways |
---|---|---|---|
M1a
F1 | A | Largeb, Urban | 2 – GP referral 3 – GP referral |
F2 | B | Medium, Mixed Rural/Urban | 2 – Self-referral 3 – No service |
F3 | C | Medium, Mixed Rural/Urban | 2 – Mostly self-referral 3 – GP referral |
F4 | D | Medium, mostly Rural | 2 – Mostly self-referral 3 – Pilot service (both) |
F5 | E | Large, Urban | 2 – GP or secondary care referral 3 – GP or secondary care referral |
M2 F6 | F | Large, Urban | 2 – Self-referral 3 – GP referral |
F7 | G | Medium, mostly Rural | 2 – Dietetics or self-referral 3 – GP or secondary care referral |
Themes
Main theme | Sub-theme |
---|---|
Weight management service issues |
Mainstream versus Insecure funding
Medical versus Social model
Access versus Capacity
|
Role of primary care |
Referral versus Signposting
GP versus Practice nurse
Practice versus Community level
|
Communication with primary care |
Local versus Centralised models
Weight loss versus Wellbeing messages
Engagement versus Resistance
|
Weight management service issues
A number of interviewees gave their views on why it was so hard to secure funding, which can be summed up as a lack of a coherent – and powerful – voice lobbying for resources.“We know for a fact that we will not have any physio input without funding, we won’t have any psychological input without funding and even simple things like venues and resources we are fairly limited for that as well.” (F2)“My effort to get an NHS board to invest in adult weight management was, em, unsuccessful let’s say.” (F3)
The second tension related to weight management services was between applying a medical or social model to the management of obesity. On the one hand, interviewees recognised that the scale of overweight and obesity (affecting two-thirds of the adult population) is such that wider population measures need to be taken, but on the other hand the approaches used by the services were often individually-focussed, treating obesity as a chronic disease.“I find it all quite frustrating to be honest because I think it’s going back to… the fact it needs a very sort of cohesive group with somebody who has clout at the top and is able to get the argument for more resources to be put into weight management.” (F4)
This represents a significant change of approach compared to other health boards in Scotland. It is the closest to a social model of obesity, with a focus on supporting patients in their context and challenging stigmatising societal attitudes to obesity.“In [health board G] we take a particular approach to weight management which isn’t about weight loss. In fact, we particularly, we try to get people to stop focussing on weight loss as a goal and look at health gain. So what is it about, the question we ask people, we say to people, ‘what is it about weight loss that’s important to you? And let’s work on that.’ So it might be that ‘I want to play with my grandchildren’, ‘I want to feel better about myself’, ‘I want to get my diabetes under control’, ‘I want to develop a better relationship with food’, you know. So that’s what we focus on.” (F7)
Several approaches to the access versus capacity dilemma were described. The most common approach was the use of group sessions rather than one-to-one sessions for weight management classes.“When we set it up there was a lot of people around the table saying ‘we don’t want to promote this heavily because we think we are going to be inundated.’ We’ve not been...” (F2)“We hadn’t actually gone out to GPs and said, ‘send us all your really overweight people’, because we were worried that would be overwhelming.” (F6)
Another approach was to work with local authorities or businesses to make use of their resources.“What has taken a lot of time to get engagement from our own, our own colleagues to do, is to apply a group approach because previous to that it was a one-to-one approach. They were able to show if nothing else from that is that on the basis of that one-to-one approach all they could address is 0.5% of need. A group approach we are now up to expecting to be able to address 2% of the need.” (F3)
There were further considerations related to improving access to weight management services, which can be thought of in terms of both structure (e.g. location and timing) and process (e.g. self-referral or GP referral). The latter is explored in the next section.“In [health board F] we decided what we were going to do was we were going to upskill leisure colleagues, to deliver on our behalf.” (F6)
Role of primary care
In contrast, those who advocated formal referral believed the GP ‘gatekeeper’ role was important, selecting those patients who may be most ‘appropriate’ for a weight management intervention.“I do think it should be, the onus should be on the person to think ‘right okay, that’s for me and I’m going to phone up about it and book myself onto a place’ rather than involving more paperwork, etc., etc., of a sort of formal referral going in.” (F4)
Furthermore, they highlighted the role of the GP in managing risk related to the referral, as this quote shows:“The model of care that we are providing in Tier two is, the gateway is the GP, so the GP will have identified with the patient and assessed their willingness, readiness to change.” (F1)
Thus, some interviewees saw a clear role for GPs in risk assessment prior to referral. Others, though, felt that practice nurses were in a better position to engage with patients about weight management. The second tension, therefore, focussed on role remit and responsibility of GPs versus practice nurses.“So we got agreement from all the clinical leads that this question could be put on [electronic referral system] which runs through, the benefits of this – undertaking physical activity – outweigh the risks involved and there’s a big exclusion list and we got sign up that that is now on [electronic referral system], so that gives us assurance ‘well the GP has done that risk assessment’… so the GP is saying yes… so that gives us, well we can move ahead with our physical activity so I think that’s really important.” (M1)
“I think practice nurses think they have got more of a role in weight management in the talking to people and supporting people with their weight. I think in a traditional model a lot of the time might be that people come to see the practice nurse to get weighed because they know they have got a good set of scales.” (F7)
The third tension was between viewing primary care as a ‘hub’ of weight management activity or more of a peripheral player. It also relates to the extent to which general practices should be engaging with other community activities and services related to weight management, which ties in with the earlier tension between a medical or a social model of weight management.“I think it should be a routine part of care that there is a set of scales that you go on if you are coming to be treated for your blood pressure and you’re overweight, or your diabetes and you are overweight. Or your asthma and you are overweight, you know, it’s, practice nurses are in that routine and it's part of their care but I’m not sure if the GP would always do that.” (F1)
The above quote reflects this tension and suggests that practices should be looking beyond their responsibilities to individual patients and be thinking more about their place within communities.“…part of this coming through that not to medicalise their weight problem too that there are other things that the patient should perhaps be given, steered into and, you know, I suppose that’s part of what our health and social care partnerships are about, trying to encourage more access to physical activity, healthier eating… and I think more and more general practitioners are trying to be, well part of the process and philosophy is to try and encourage those communities in the health centre so that there is more and more information available there that the patient can be, not directed, but you know, give them a steer towards and I think there is more of that going on now.” (F1)
Communication with primary care
In contrast, the more centralised models used more impersonal approaches such as various forms of electronic communication – email, website, intranet, or electronic newsletter. Of course, it is possible to use electronic communication in a personalised way – for instance, by providing practice-specific feedback on referrals by email – but this did not happen very often. Most services used a mixed model, with both central (impersonal) and local (personal) approaches.“We are starting to do, like, raising awareness sessions and just talking to some of the practice nurses in [health board B], you know they are quite interested in getting involved…” (F2)
There was a feeling that in those areas where there was a previous history of working closely with practices (e.g. with a related service such as Exercise on Referral), the services benefitted from this improved relationship.“Each time the service moved out to a different [area] every practice was emailed and lettered with the referrals, information over here, and we also invited them to come here, or asked them if they’d like someone to come to the practice, and we’ve been to many practices.” (F5)
Method of communication was a key consideration. The more personal forms of communication were preferred by most, as the following quotes demonstrate.“What’s interesting is that where there has been long term sort of work between the local authorities and the GPs and practice nurses in the area they are getting much better referrals coming through. So where there is already a partnership, a relationship built up, they are getting, you know, they are getting frequent referrals coming through. In the areas where that’s not as well established then you can kind of see the difference.” (F2)
“It’s very difficult sometimes to have a relationship with people if you have never actually met them, or the first time you are on the phone is to say ‘no I’m sorry this patient doesn’t meet our criteria for the weight management service’.” (F1)
The second tension related to the message being communicated to primary care practitioners by the service, between stressing the importance of weight loss versus more holistic wellbeing messages. This, in turn, is likely to affect both how practitioners ‘sell’ the service to patients and patients’ expectations of the service. This was a tension felt most acutely by the service in health board G, which had adopted a Health at every size approach.“I still I think a lot of it is down to the communication aspect again and so I think that doing more face to face communication with people and raising awareness, so whether it's, you know, attending whatever kind of meetings so that you can have more of a conversation about it would be helpful from that point of view because I think, I do think, you know, email, etc. has its place and it is very useful but I don’t think anything, you know, kind of compares to face to face” (F4)
A key aspect of this tension is about shaping GP expectations of the service, by providing them with information about what is considered a good result. For the majority of services where weight loss was the ultimate goal, it was important to make referring practitioners aware of the realistic weight loss outcomes from the service.“We are now in the position to go and have a few more discussions with GPs because really what we don’t want is - because of the approach we take - we don’t want GPs to tell people to lose weight all the time.” (F7)
Finally, there was an evident tension around the GP responses to attempts by weight management services at engagement with primary care. When asked about previous contact with primary care, the following exchange between two interviewees in health board A gives a sense of the challenge:“…in all our discharges we put on, ‘five kilogram weight [loss]’, and we reference SIGN [national guidelines], and ‘this is considered successful and a clinical improvement.’ And, we put it in every bit of our literature that we can, because that is an education to our referrers.” (F5)
The second quote above refers to the Quality and Outcome Framework (QOF), which was a pay-for-performance system that was used in general practice in Scotland at the time of the interviews, but has since been replaced.“I think it’s so variable. You know I think some of our lead GPs have been fantastic at opening the gates for us.” (F1)“But then you get other GPs who say ‘well I’m not doing weight management until you give me money’, so it’s ‘give me money’.” (M1)
“Many many people in primary care… didn’t see weight management as their business.” (F5)